Depression and Anxiety can present during the postpartum period. Many women may require pharmacological treatment while breastfeeding. The decision to continue breastfeeding, choose a safer medicine or discontinue either depends on multiple factors.

Many women with postpartum illness delay treatment because they are worried that the medications they take may harm the baby, but the research data and expert opinions indicates that the risk of adverse events in the nursing infant is low.

If a mother on psychotropic medications is breastfeeding the newborn should be regularly monitored for possible side effects like drowsiness, hypotonia, rigidity, tremors, and withdrawal symptoms. Preterm immature infants should not be exposed to psychotropics.

General Principles

Breast feeding has many established health benefits for the baby, so some women taking psychiatric medications for anxiety or depression may wish to feed their infants. When making this decision, several variables must be considered. These include the known and unknown risks of medication exposure for the baby via breast milk, the effects of untreated illness in the mother, and the benefits of and maternal preferences for breastfeeding.

From the available data, it appears that all medications, including antidepressants, antipsychotic agents, mood stabilizers, and benzodiazepines, are secreted into the breast milk. However, concentrations of these agents in breast milk vary considerably. The amount of medication to which an infant is exposed depends on several factors: factors pertaining to the specific medication, the maternal dosage of medication, the frequency of dosing and infant feedings, and the rate of maternal drug metabolism.

The decision to breastfeed while taking medications is more complicated when a baby is premature or has medical complications. It is a good practice to recommend low dose of a single medicine to breastfeeding mothers. In premature infants or in infants with signs of compromised hepatic metabolism (e.g., hyperbilirubinemia), breastfeeding should be ideally stopped because these infants are less able to metabolize drugs and may be more likely to experience adverse events.

Antidepressants

For women taking antidepressants the relatively safer choice would be SSRI’s like Fluoxetine, Sertraline, Paroxetine, Citalopram. Studies show that the amount of drug secreted in breast milk to which the nursing infant is exposed is low and that significant complications related to neonatal exposure to antidepressants in breast milk appear to be rare. Typically very low or non-detectable levels of drug have been detected in the infant serum, and one recent report indicates that exposure to medication in breast milk does not result in clinically significant blockade of serotonin (5-HT) reuptake in infants.

However, there have been a small number of case reports of adverse events in infants exposed to antidepressants in breast milk, including jitteriness, irritability, excessive crying, sleep disturbance, and feeding problems.

Many clinicians and their patients ask which antidepressant is the “safest” for breastfeeding. It is somewhat misleading to say that certain medications are “safer” than others. All medications taken by the mother are secreted into the breast milk, and there is no evidence to suggest that certain antidepressants pose significant risks to the nursing infant.

Anti-Anxiety Agents

Benzodiazepines are frequently used during pregnancy and post partum period. Available research suggests that the amount of drug to which the newborn is exposed in breast milk is relatively low and the incidence of adverse effects is low.

Mood Stabilizers

For women with bipolar disorder, breastfeeding may pose more significant challenges. First, on-demand breastfeeding may significantly disrupt the mother’s sleep and thus may increase her vulnerability to relapse during the acute postpartum period. Second, there have been reports of toxicity in nursing infants related to exposure to various mood stabilizers, including lithium and carbamazepine, in breast milk. Ideally lithium, lamotrigine and carbamazepine should be avoided in pregenancy.

The American Academy of Pediatrics has deemed both carbamazepine (Tegretol) and valproic acid (Depakote) to be appropriate for use in breastfeeding mothers, few studies have reported that nursing infants exposed to these agents may be particularly vulnerable to serious adverse events. In those women who choose to use valproic acid or carbamazepine while nursing, routine monitoring of drug levels and liver function tests in the infant is recommended. In this setting, ongoing collaboration with the child’s pediatrician is crucial.

Antipsychotic Agents

Conventional antipsychotics have been used over decades and accumulated data show they are relatively safe during pregnancy. Information regarding the use of antipsychotic drugs is limited and is particularly lacking for the newer atypical antipsychotic agents.